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HomeMy WebLinkAbout020-1301-50-000 3 CCD I ) a 0 m N 0. 0 I e I I 0 N I C 'C O 0 z o C _ O 3 c9 O LL o m w N a Q r I v Z rn N E 0 0 z c\i ~ a co O ~ I u O Z v c L D w o a N H r z -2 m co N , O a) co n a) c N U) .0 O _ o a°i Q :w z co z o N z N E c E CV w N L Q r N C n a) i O tv d o FN- H H ~ o 0 ~i O O O a m z a I c 0 W N 0 "t "T rn rn aNi (n U m rn } ~ O eN-- E O ` N O y'- O O a) co N ~ a u N m Q } U) Q O 3 w O O V U) O o o r> c `o E O O c N :3 I l s, H co N E E ra -r -0 v W O C co m c O O 7 N C .M r N COO d N I- ~ N 7 a) N O N E E N U Tf 04 CD z a y Q L: w a w -1 A 0a2,'o n0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER r V~ JJC ADDRESS Cloven L2 A ~ i J-'e pups©~ ~~Sc. S`f~l SUBDIVISION / CSM# Tta2K ul'?V) E14Al Zs LOT # Hj _ SECTION l T QI N-R I q W, Town of I uDSON ST. CROIX COUNTY, WISCONSIN PLAN VIEW SH W EVE THING WITHIN 100 FEET OF SYSTEM IaGo9A), y BeDROO rn ran►K I~ix48 Bed ►v a3' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ~,1 d N d NQ-X I ALTERNATE BM: SEPTIC TANK / BER / H ION Manufacturer: Wei kS Liquid Capacity: IN O Setback from: Well N6-( ►N House (SI Other Pump: Manufacturer Model# Size r Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: a 3' Setback from: well : NGt 1►.► House oQ (o Other Hl-A01eR 97-" 91•~~" 17.06 ELEVATIONS CoVeK U(o.a7 Building Sewer ST Inlet. Va. Io~ ST outlet U PC inlet PC bottom Pump Off - Header/Manifold Bottom of system 907 Existing Grade loo-l Final grade 00 DATE OF INSTALLATION: IQ ` )PLUMBER ON JOB: ZSLt/Y~LICENSE NUMBER: U INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ,.Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit WERTder Bs Name: RIAN ❑ City Village Town of: State Plan WO CST BM Elev.: ~ Insp- BM Elev.:-m i BM D scriptio Parcel Tax o. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark d , Septic y7e Q Dosing L~ . 06.14y. / 03, 8 Aeration Bldg. Sewer Hol St /,K Inlet 7. S7 Cb?, /fl TANK SETBACK INFORMATION St/ t Outlet 1111 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic n,4 NA Dt Bottom - Dosing NA Header/ 12-14' 7 Aeration NA Dist. Pipe Z 97 d 7 ' H Bot. System /3 PUMP / SIPHON INFORMATION Final Grade , Manufacturer I Demand Q Co 33 Model Numbe GPM TDH Lift Friction TDH Ft loss ea For ain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length i No. Of Trenches PIT Of Pits Inside Dia. Liquid Depth DIMENSION /g C DIM N I N SYSTEM TO P/ L BLDG7 WELL LAKE / STREAM LEACHING r' SETBACK INFORMATION Type o e<, , CH Mode Num en System: -v 2 UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. r Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems On Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / TCenter Bed /Try Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)- /4S tw~ LOCATION' HUDSON.17.29.19W SE SW LOT 114 CLOVE LEAF CIRC Plan revision required? ❑ Yes No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COUNTY ~ In accord with ILHR 83.05, Wis. Adm. Code ~ 1 , COCA' STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~J tl/6 ? 9 8% x 11 inches in size. c eck ffirevision o previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION R WQ 5 /455 '/a, S I r7 T , N, R E (or) W i t_ PROP OWNER' MAIL N! D RZ$Sft 4 I LOT # BLOCK # 1 C", STATE Zlf? DE PHON NUMBER SUB VISI A OR CSM NUM R / V (^A ) ~p ae el,J 2 0, f't4bs ON )S C. 5 y V II. TYPE OF BUILDING: (Check one CITY NEA EST ROAD ~ ) El State Owned ❑ VILLAGE : Jp J CJ OV"n n~ \ ) ❑ Public R1 or 2 Fam. Dwelling- # of bedrooms Y PAR EL TAX NUMBER( S). 111. BUILDING USE: (If building type is public, check all that apply) CAD 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. [gNeW 2. ❑ Replacement 3. ❑ Replacement of 4.E1 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ..Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE RE IRED sq. ft.) PROPOSED sq. ft.) (Gals/ y/sq. ft.) (Mi inch) 9W7 ELLEVATION V lJ tS~6 .7 Feet lop-17-Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concr to Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb is Name (Print): PI er's S' ature: (No Sta ps) MP/MPRSW No.: Business Phone Number: statt PlurpbC) Address (L eI~_ S ZIP CJ ' ! " AU V S D N L~A 5C (J I . COON IyTYIDEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e ssue uing Agent Signatu o ps) Surcharge Fee) c pproved ❑ Owner Given Initial 00 T -Z Adverse Determination ! U X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) `6 PLOT1-11, ~.11~055 r. P I7 ~J E C, 1 e . _ N 111111 ~ f'. rv~ you -e s PN ~e _ NAME 0 _u C,~-~}e I~~I C E N S E 0 C. 1 N ova . SV . . Iw C.... P.L.. 0 i . _ _ • . ~ la„ ~od. ~ a~► g~~ Nckv • Ad~ a I15 ) Sd, 9?y- Q ~ , s It~I ,1flK~. as 5~~; sy ems. p s ya gy p~ ~tv CIRcr~ . FRESH A'ilt If:L[:'1':i AND OBSERVJI'P10Nf'YI•QE C1:0SS SECTION - Approved Vend Cap Minimum 12" Above 0o 7 A" Cast Iron Above Pipe Venj Pipe To Final Grada - I Marsh stay Or ~Synthetic Covcri.ng_ Min. 2" Aggr.eljIl;1100 Over Pipe Tee Distribution- _.I pipe rer•foraeed Pipe Delot•1 Aggregate n~ 1 1)c~icath Pipe 'e, Coupling. Terminal:~.ng' N Aol•tom: of System.... ; ~1'.1w11.~ Ni. 1 . 1 1 w11w• .i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations DiviFion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ° Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but Sf ~r~ i not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROP PTY OWNER: PROPERTY LOCATION All GOVT. LOT t-)' 114 5 ~ 1/4,S T C N,R '9(or& PR E TY OWNERS MAILING ADD ESS LOT,# BLOCK # SU D. N E CSM # i ~'rcl c/ T 00 ;Yw hS "'fit S CITY~,TAT ZIP CODE PHONE NUMBER ❑CITY VILLAGE WN NLWE~T ROA tre~,) ~c o -O l - ``a Gt~o~, ffo I New Construction Use Residential / Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe 1 Code derived daily flow OO gpd Recommended design loading rate Z_bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 _trench %ft2 Maximum design loading rate , -Z_bed, gpd/ft2 . trench, gpd/ft2 Recommended infiltration surface elevation(s) q / 17 ft (as referred to site plan benchmark) Additional design / sitel Jconsiderations l Flv /I/ . ~a /1 YU;~ 1!'lf t Parent material "y„rc n Pr, Z-1 Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for s stem S ❑ U ❑ U J9S ❑ U S ❑ U ®S ❑ U ❑ S aU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncfary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench U .17' Ground 27"T S n y SP, Fs S 9'' f/ - - 7 elev. / ft. Depth to limiting factor,,,, L'VV ~ 1 - vt,/ nG/,'L l Remarks: Boring # lei lz-lz 2 -loo S 2 S/ 5 f / Ground elev. 1012 ft. Depth to limiting fac r /PD' Remarks: CST Name ale Print Phone: a 6~ a !1e 3~d /c~L9 Address: f/1-; 3s' Signature: Date: CST Number: 7y, Cj 3 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of - PARCEL I.D. # t Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0 4 7-5 y l ~r IfliC {M C Ground 3 %A,. 5'Y11 / elev. ft. Depth to limiting factor , Remarks: Boring # p ON ~2 IM, y rF Z . ~L: S r sl4 ),.,ray r C- REM 112 .•5/-. ~ ~ 3 / r o, P Ground elev. /dc. s ` ft. Depth to limiting factor Remarks: Boring # - S 3 SIB 9r r ~~f ' 40 r Ground elev.., Depth to limiting factor /D, /7 Remarks: Boring # I Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) 3e/ f rz ~y 14, r,+ c ~,I ,00'Ob£ 100*01z: ,0.69 0'00£ S9E ,00'6Sz $ N 0 8 U) I N M _ In (6 C\j C,4 ap Ito F- o M OI O _ I 1 ' \ O o N N x a OLs9i O O I . ' Fs 9~~ J o o oo g I> I M is 0-6r.Z'-7 13 W N N c 006 O (C) 37 YO AY038 a - - AIRY `y 9 h - - O _ - 00'00£ \ ,J \ ,00 Z61 - 2 ~ m ooa \ 0 8 o N $ 9~ Ye s9£ p, g rn C\l ^ p ~s o ~n o ti ~ M O N ~ a N ~I N N - p O M J N OJ - p0'6sz r• 100,V02 00 -01Z N N Q"~b0~2tQ i 1 ,00'Z61 N ss I OO'SS 1 '00S I ~ \ f~ p . b1. CV N ~ u g - O d / 6 to 0 8 n e n - cv a t N o S~lti153 I of I ° Main o N ppp I 821 I M O O I I ~1 L01 16M~ 052 I J Z01 / 101 I 0, / ,6~ \6`66 .6g6Fgo4I~ 3, .zi LZI .00'99I l NOIi~40V SS I I - 3,yZ, J B` I M ---j cr go-012 Hi8noi 83: R d m a m •ys2 a I 0I Wio F- c °m Og'. p I 1.16'ilt M_02.90.00S1 Vl N I uu .0~ J 00'01£ I ZZ'£1£ M.90,bZ.00N NI 8; 00N bE'99Z o e o F- a r Ln t cr r lB►"402 M,Of,90.0061 Z ^o u 60'bOZ a ^ F- a N M. S,9,90.00N .66'ICL M.Zf,Bb.20N , 6 'O ~ ,M 201 O. \ 0 b O 2 O .j g ,60221 ,60642 ~-r J _ - p rr \3 is 1~ V` O SOlf26'aeE _ n r• N W,. rn.t (~c^ MuN : q' dF a MuN ae MAo 0. 4 "1 O O$ °r Jae 0. ^ ~O r - ? nu I s /JC\ fr s3 \ J „ O ~ 1 ~yids~ rr p \ a 3 4 z9t G~[` \ wed \ ~•D \ 09 as o-I s 3 Mvo v®~ 016 MNLL m J-~ E 01 v1 0 ~ 5}hod 29 ~ ~ ~ o R 20~ei o c 9 'ry n OZ C6 ao 6 G I 3.92.LOJ06 ON .m~ 4`~' n (D .L $ \ SY W p vi 1 A M4 10 v O ~NLL ONE $ M O „ ,n W N u'^ Fam i Z H : OMe \ Qnv o JQ $ °a Og". J J=1O \ 604 _ _ 113w35V3 39VMVtl0 \ V2199Z oa eot oz-191 N I R It cot = ,611e 00091 ees►z m'O[t l3 .M On<1 - 13,04,9t.0o41 169.9041 3.9£,L0.I0S [t N ~ - O co 16 ,15 to tQi J In 6LOV STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L 7ulAki MAILING ADDRESS 2 i~x oZC.l'i- PROPERTY ADDRESS eWU2 0,4F (?Aeu) (location of septic system) Please obtain from the Planning Dept. CITY/STATE • LQ:I-- PROPERTY LOCATION SO 1/4, l~ 1/4, Section, T~N-R W TOWN OF VpS 6' ST. CROIX COUNTYY, WI mot, SUBDIVISION PF}2.K U 14 v.: 'CST-" 5* f} o l)- LOT NUMBER f yY_ CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three ar expiration date. SIGNED: p DATE: S - 8 r y St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed, Any inadequacies Will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Of property pF}~(z~ GJ1 ZBPIA~j r _ Location of ro ert p p Y~ 1/4 .sw 1/4, Section T - N-R Tc" nship - gV o5~~K3 tailing address Address of site - a~ Subdivision name P N ~ A-10 Lot no 1 C( Other homes on property? -_Yes_ >C NO Previous owner of property Total size of parcel Date parcel was created 1~19 'p(}'' i ?7R !.re all corners and lot lines identifiable? Yes No Is this property being developed for (spec house ? Yes X140 Volume 5'(®y and Page Number f of Deeds _~!./z_ as recorded with the Register IN,"1,U7DE WITH THIS APPLICATION THE FOLLOWING: F;AI<R-ANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THL SELL OF THE REGISTER OF DEEDS. certified survey, , would be help In addition, a if available elful so as to avoid dela_;s of the reviewing process. If the deed description references to n Certified survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CEZTIFICATION cent -ify that Rill statement:-; on this form are true to the "st of my (our) knowledge that I (we) am "~e >roperty described in this information f(are orm) by owner(s) of "'tzantY deed recorded in the office of the county Regis of a (ieds as Document No.t~'~°?7 Y ter of o n the , and that I (we) presently proposed site for the sewage disposal system or I (we) twined an easement, to run the above described property, for construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document Siu_nature of applicant r o-applicant Jate of Signature - Date of Signature_ I it r , DATA NO. WARRANTY DEED li THIS SPACE RESERVED FOR RECORDING II ! STATE BAR OF WISCONSIN FORM 2-1982~1 521324 Darrel E. Wert and Beverly A. Wert, husband and wife, - individually - and each in their own. right . I S EP 13 1994 ' :20 f it M conveys and warrants to _ Brlan E. Wert and JOAnn L. Wertf s ~-'~C. husband. and wife. as. survivorship_marital.property----_---- U ~~sterOi C~3 - n= >v...~ ,,.a,........,,. I - RETURN TO~•~ II i~ . ~t _.-St. ('`ro1X _ ...............County, tt(/`SE7v\~S -O~ Ul to the following described real estate in --St-----. i' State of Wisconsin: Tax Parcel No: Lot 144, Park View Estates Sixth Addition to the Town of Hudson. ~ I i Y- I This 1.S riOt---------- homestead property. M (is not) Exception to warranties: TOGETHER WITH AND SUBJECT TO any other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances beyond the term established by law therefor. Dated this day of Septenlber----------•------------------------ 19.94 (SEAL) - (SEAL) Darrel E. Wert -----(SEAL) _ 255~ ~ * Beverly A. Wert i AUTHENTICATION ACKNOWLEDGMENT Signature (s) Darrel__a._-Wert _r7nd--•-_-__•_-_--__- STATE OF WISCONSIN Beverl A. Wert SS. ka ~i--SeptembPx 94 •-•----•------•---•------•-------•----County. authe y of________________•__-_-____, 19...... Personally came before me this _-_____._____-_day of 19----•--- the above named !7_~•------------------------------- I`I/ A Hugh in TITLE: MEMBER STATE BAR OF WISCONSIN (If not, aut orized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Hugh H. Gdi.n 430 2nd St., Hudson, WI 54016 Notary Public -----------------------------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19-_--.. 'Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. EO '11Z9 fA